A Comprehensive Rehabilitation of a known Case of Leprosy Operated for Midshaft Femur Fracture

Background: A persistent infection triggered by Mycobacterium leprae is also known as leprosy or Hansen's disease, transmitting by tiny droplets of the nose and mouth to the skin and peripheral nerves, producing disability. Leprosy therapy is based on the combination of the rifampicin, dispone and clofazimine (MDT) three-drug regimen. In patients who undergo hormone therapy, avascular femoral necrosis (ANFH) or femoral head osteonecrosis (ONFH) may occur, causing steroidinduced femoral head avascular necrosis (SANFH) Core decompression (CD) reduces bone pressure, opens the hardening area, prevents osteonecrosis repair, promotes blood vessel development through the tunnel for decompression, increases bone replacement and delays osteonecrosis. Patient information, diagnosis and therapeutic interventions: In this case, we found a 20 years old girl known case of leprosy, was on corticosteroids for two and half years. After an increase in dosage of corticosteroids she began difficult for her walk and do her activities of daily living. She visited Acharya Vinoba Bhave Rural Hospital (AVBRH), DMIMS (DU) Sawangi Meghe, Wardha, Maharashtra, India where she got to know about necrosis of head of femur of both lower limbs. She Case Report Vaidya et al.; JPRI, 33(38A): 299-306, 2021; Article no.JPRI.71119 300 underwent core decompression surgery of bilateral femoral head. For further management she was referred to Physiotherapy Department. Outcomes and Conclusion: this case, we found that a patient who is young who had Midshaft femur fracture with interlock nailing and sever kinesiophobia, affecting rehabilitation, was able to resume her ADLs independently.


INTRODUCTION
A persistent infection triggered by Mycobacterium leprae is also known as leprosy or Hansen's disease, transmitting by tiny droplets of the nose and mouth to the skin and peripheral nerves, producing disability [1]. Leprosy therapy is based on the combination of the rifampicin, dapsone and clofazimine(MDT) three-drug regimen [2].
Corticosteroids have many reverse reaction effects on the disease. Reverse reactions are immunological responses and are the main cause of disability. The standard therapy for reverse reactions is glucocorticoids [3]. In patients who undergo hormone therapy, avascular femoral necrosis(ANFH) may occur, causing steroid-induced femoral head avascular necrosis(SANFH) [4]. Avascular femoral head is also known as femoral head osteonecrosis [5]. in which bone reshaping and cell death induced by insufficient blood supply [6] to head of femoral, triggers deterioration as well as associated bone cell recompense with marrow of bone, resulting to change in structure of the head of femur and head of femur collapse [5].
The non-traumatic risk factors for AVNFH include radiation therapy, haematologic problems, excessive glucocorticoid use and overuse of alcohol [6]. The symptom of these patients typically consists of pain, frequently found in their groin; this pain can impair movement (ROM), in particular passive internal rotation, dramatically decreasing regular daily living activities and consequently the quality of life [7]. Increased blood viscosity may contribute to femoral head vasospasm, thus deficient blood oxygen in the head of femoral and then a loss of osteocyte function and cell death. Which triggers a division and area of head of femur which have microfracture in the trabecular bone which bare the weight [4].
Core decompression (CD) reduces bone pressure, opens the hardening area, prevents osteonecrosis repair, promotes blood vessel development through the tunnel for decompression, increases bone replacement and delays osteonecrosis [5].

PATIENT INFORMATION
In this case, we found a 20 years old girl with complains of tingling, numbness in limbs and itching over low back visited local hospital where she was diagnosed with leprosy. She was on corticosteroids for two and half years. After an increase in dosage of corticosteroids she began to complain of pain in both hips while walking, standing, bending forward and sit to stand activities. She visited AVBR Hospital, (MH) as the pain increased making it difficult for her walk and do her activities of daily living. She had been diagnosed with bilateral femur head avascular necrosis. She underwent core decompression of bilateral femoral head surgery. For further management, she was recommended for physiotherapy.

Findings from Clinical
Her examination was done at same level with both shoulder in a supine lying position. Upon inspection, the patient maintains both legs abducted and a bit internally rotated, both knees supported with pillow in extended position, legs and ankle, both ankles slightly plantar flexed. Presence of swelling on both hip & site of operation. On palpation, there was rise in temperature of local area, and oedema which was non-pitting. No failure of superficial sensations was found (pin prick, light touch and temperature and light touch).

Post-operative
Air-related complications are prevented short term, pain and oedema are reduced, joint range of motion and strength is maintained and increased, early mobility is promoted, pressures are avoided, walking is encouraged, and the ADL activities are independent. The long-term objective was to support independent walking (partly/full-weight), static and dynamic bala with or without a walker.

Management
Phase I (0-3 months): Phase I exercises emphasis on counselling, knee and hip strengthening, bed mobility and mobility of joint.
Immediately after surgery, active motion range, knee bending exercises, and lower limbs are initiated. Cryotherapy and limb elevation were frequently used to resolve effusion and oedema. In an immediate strengthening, extensor of knee with active control musculature and abductor of hip was concentrated. To Strengthen a nonweight bearing position, chain which is open practice such as removal of hip simply, flexing and extension exercises have been done. During these training workouts, attention was given to maintaining a quadriceps with complete contraction which must be powerful in a completely longer posture with the being. The knee extension was actively carried out without weight in a sitting position.

Phase II (3-5 months):
Phase II involves exercise of Phase 1 to boost bearing wight work , few gear re-educating, leisure tasks and startups. Crutch weight bearing was tolerated with minimum to partial weight. Reinforcement to weight-bearing with minimal weight and by crutches and hand-bearing weight. More weightless exercises have been introduced, such as knee flexion and resistance bands extension.
Increasing the duration of the exercises achieved in terms of strengthening by increasing resistance with progressive resistance exercises (PRESs). Hip reinforcement evolved by practice such as kidnapping and standing hip flexion. In addition, weight bearing advances of up to 50 percent with a support method stared at strengthening exercises such as step-ups. The knee extension and the abduction of hip movement are continued. Increased resistance and greater repetition were given to training at Phase I.

Phase III (5-7 months):
The exercise focuses on accelerate the strength of the lower extremity through weight of partial weigh, maximum weight exercises to weight-bearing functions during phase III in order to enhance mobility, balance, proprioception, coordination and agility training. Phase II exercises proceeded according to requirement.
Stable platform practices were progressed to improve the dynamicity of stable and unstable surfaces while preparation was improved by emphasizing the need to apply more natural gear patterns. In addition to reverse walking, training gaits have been carried out with appropriate assistance to facilitate side-stepping movement. Improvements in intensity, normalization of gait and a potential transition to preferred activities.
In terms of strengthening, the duration of the exercises initiated by the improved PREs is increased. Similarly, individuals who perform task like step-up, half lung and mini squat for weight improvement up to 100% with or without crutches. Lateral walking with resistance is the advanced techniques used for the hip abduction strengthen in close chain exercise.
In weight bearing with or without aids the balance and proprioception training were advanced as one-legged activities. Strong Platform exercises on solid and unstable surfaces with the transition from static balancing to more dynamic one-leg exercises during recovery with focus put on a more natural gait style.

DISCUSSION
In this case report, we found that a young girl who had leprosy and was on corticosteroid suffered with bilateral avascular necrosis of head of femur. Aim of the rehabilitation is based on the bilateral core decompression done, beginning from low intensity exercises to gradual strengthening and partial to total weight bearing with crutches. All the exercises were done three times a day of 10 sets each. With the help of rehabilitation programme, she was able to resume her ADLs independently.
We encouraged the strengthening of the gluteal muscles and quadriceps [7,8] in the hip joint to preserve the strength of the muscles.
We focused on the muscles of gluteal group , as it is essential during gait in hip stability [9]. Activation of the hamstring prior gluteal muscle group results in hip instability and anterior hip muscles. Abductor force contributions are needed prevent pelvic tilt. The prime mover will be iliopsoas muscle, TFL and rectus femoris are activated in very less amount.
ROM exercises are performed in the early stages immediately after the surgery [10]. These exercises are proceeded slowly throughout the late stage. Hence, we worked on ROM exercises, which were encouraged from early stage.
As both lower limbs were involved, we did not choose initial weight bearing during the first 3 months of post-surgery [11], whereas quadriceps isometric contraction exercise became essential to prevent muscle atrophy.

CONCLUSION
In this case study a young leprosy girl, who had secondary bilateral femoral head avascular necrosis, arising from the corticosteroids that were used for leprosy treatment and impaired recovery. The recovery program consisted of a target-based therapy program that decreased postoperative pain, oedema, increases energy, range and enhanced patient responsiveness. She was able to resumed daily living activities (ADLs) voluntarily with the help of regular rehabilitation.

LIMITATIONS
Early weight bearing was delayed as she underwent core decompression for bilateral hip for avascular necrosis.

CONSENT
The patient included in the study received informed consent.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).